The present invention is directed toward improved systems and methods for collecting and reporting Hierarchical Condition Categories (HCC). More particularly, the present invention comprises training programs and software systems useful by health plans and medical practitioners to more accurately code and report HCC to comply with the Centers for Medicare and Medicaid Services (CMS) documentation and reporting requirements.
Essential to high quality and cost-effective healthcare is the proper diagnosis of a patient's condition. From a proper diagnosis, the appropriate medical attention utilized to treat the underlying condition, whether it be the performance of a medical procedure, laboratory tests, and/or prescription of medication, can be determined. To that end, and as is well-known in the art, standard diagnoses codes are extensively utilized pursuant to conventional disease classification techniques that provide a quick, well-understood method to document medical care administered to a patient. Exemplary of, and perhaps most widely utilized of such formats, is the International Classification of Diseases 9th Edition (ICD-9) three digit codes. Likewise, with respect to the medical treatment that has been rendered, such procedures are typically referenced according to Current Procedural Terminology (CPT). Also frequently referenced in connection with the delivery of healthcare are drug codes (e.g., National Drug Code, or NDC), other service codes (e.g., Healthcare Common Procedure Coding System, or HCPCS), among others.
The Balanced Budget Act of 1997 (BBA) mandated a change in Medicare's payment methodology intended to pay health plans, and subsequently medical providers, based on a patient's health status through a process called Risk Adjustment Factor (RAF). Prior to the implementation of risk adjustment, reimbursement was based solely on demographic factors, such as, age, sex, Medicaid status, county of residence, etc.
In 2004, the Centers for Medicare and Medicaid Services (CMS) implemented a new model, the Hierarchical Condition Categories (HCC), as an additive model to adjust Medicare capitation payments to private healthcare plans for their expenditure risk of enrollees based on serious or chronic conditions. In theory, the CMS-HCC model pays more accurately for predicted health expenditures, based on health status and some demographic factors. In short, treat the patient appropriately and get reimbursed for doing so.
The collection and reporting of HCCs provides important benefits to patients and improves reimbursement. When health plans and/or practitioners have their own programs for documenting, auditing, and reporting HCCs, there is an opportunity to identify those at-risk enrollees/patients who, because of their disease markers, would benefit from increased frequency of visits and intensity of services, enrollment in complex care management, chronic care programs, and/or transitional care programs when appropriate—all designed to ensure the best possible clinical outcome for patients and cost savings for health plans and practitioners. Examples of such other programs are described in U.S. Pat. Nos. 7,657,442 and 7,464,041 and U.S. patent application Ser. Nos. 11/352,028 and 12/834,767, the entire teachings of which are collectively incorporated by reference herein.
Accordingly, there is a need in the art for a program designed to train and support health plans and practitioners the art and skill of correctly coding and reporting HCC to comply with CMS-HCC documentation and reporting requirements.